Systematic review of recent innovations in service provision to improve access to primary care.

BACKGROUND In England, there are particularly pressing problems concerning access to adequate primary care services. Consequently, innovative ways of delivering primary care have been introduced to facilitate and broaden access. AIMS The aim of this study was to review the evidence of seven recent innovations in service provision to improve access or equity in access to primary care, by performing a systematic review of the literature. DESIGN OF STUDY Systematic review. SETTING Primary care in the United Kingdom (UK). METHOD Seven electronic databases were searched and key journals were hand-searched. Unpublished and 'grey' literature were sought via the Internet and through professional contacts. Intervention studies addressing one of seven recent innovations and conducted in the UK during the last 20 years were included. Two researchers independently assessed the quality of papers. RESULTS Thirty studies (32 papers and two reports) were identified overall. Variation in study design and outcome measures made comparisons difficult. However, there was some evidence to suggest that access is improved by changing the ways in which primary care is delivered. First-wave personal medical services pilots facilitated improvements in access to primary care in previously under-served areas and/or populations. Walk-in centres and NHS Direct have provided additional access to primary care for white middle-class patients; there is some evidence suggesting that these innovations have increased access inequalities. There is some evidence that telephone consultations with GPs or nurses can safely substitute face-to-face consultations, although it is not clear that this reduces the number of face-to-face consultations over time. Nurse practitioners and community pharmacists can manage common conditions without the patient consulting a general practitioner. CONCLUSION The evidence is insufficient to make clear recommendations regarding ways to improve access to primary care. In the future, it is important that, as new initiatives are planned, well-designed evaluations are commissioned simultaneously.